New Patient Paperwork – 2019
Center for Weight Loss Success, P.C.
Patient Data Sheet
PLEASE WRITE LEGIBLY DATE__________________
Name of Patient_____________________________________________________________________________________
Last First (Jr., Sr. optional) Middle Nickname
Date of birth:________________________ Sex: ____ Male ____ Female SS#__________________________________
Home address:______________________________________________________________________________________ (cannot accept P.O. Box as home address) Street Apt#/Bldg# City State Zip code
Mailing address:____________________________________________________________________________________ Street Apt#/Bldg# City State Zip code
Home #__________________ Work #__________________________ Cell #__________________________
E-mail address:________________________________________ Can we contact you via E-mail:_____Yes _____ No
How do you prefer that we contact you? ____e-mail OR _____ phone
Occupation:______________________ Employer&Address_________________________________________________
Marital Status: _____Single _____Married _____Separated _____Divorced _____Widowed
Level of Education: _________________________________________
Spouse’s name:___________________________________ Phone number:____________________________________
Guarantor Information/Person Financially Responsible for Patient Bill
Guarantor’s name:_________________________________ Date of birth:______________________________________
Social Security number:_____________________________ Home phone:__________________ Work:______________
Primary
Insurance________________________Address____________________________________________________
Subscriber_________________________________________________Subscriber Date of Birth____________________
Insurance Phone#__________________________ Policy#_______________________ Group#_____________________
Secondary
Insurance_______________________Address___________________________________________________
Subscriber_________________________________________________Subscriber Date of Birth____________________
Insurance Phone#__________________________ Policy#_______________________ Group#_____________________
Who should we contact in an emergency?
Name:______________________________ Relationship:____________________ Phone:________________________
Who is your primary care physician (PCP)? Dr.___________________________________________________________ First Last Phone #
Who referred you to us? ___________________________________________________________________________
New Patient Paperwork – 2019
Center for Weight Loss Success, PC - General/Financial Consents
FINANCIAL POLICY
I understand that payment is due at the time of service. I also understand that purchase of any weight loss surgery or
medical program will have an individualized term of agreement document for me to review and acknowledge prior to
purchase. I acknowledge that for any surgical care, payment must be received prior to surgery and I understand that non-
payment will result in surgery cancellation. I acknowledge that no goods or services provided by the Center for Weight
Loss Success are refundable at any time. This includes, but is not limited to, program fees, supplements, exercise
accessories and personal training sessions. Supplements and exercise accessories may not be returned.
I understand that at the completion of any weight loss program I have selected and paid for, all contents and offers
including but not limited to, counseling sessions, and supplements, will expire and are not redeemable. For medical
weight loss, I am required to start my program within the time frame of the program selected from its initial purchase
date. Deposits expire within 3 months from the initial purchase date. However, deposits are not transferrable toward any
other products, services or programs. Personal training sessions, lifestyle education classes, group exercise classes and/or
counseling sessions purchased separately will expire 6 months from the date of purchase. I also understand that there will
be a $35.00 returned check fee (paid only by money order, cashier’s check or cash) for each check returned for
insufficient funds.
I understand that co-pay’s (when applicable) are due at the time of service and I am responsible for any balance un-paid
by my insurance, and that it is not the responsibility of Center for Weight Loss Success to be sure that my service(s) are
covered, thus I understand that any questions that I have concerning my insurance coverage should be directed to my
insurance company. I also understand that, if my insurance requires a referral for specialist visit, it is my responsibility
to obtain (referral) from my PCP, and that my signature below also acts as a waiver accepting financial responsibility if
my insurance requires a referral and I choose to receive services without one.
REQUEST FOR RELEASE OF MEDICAL RECORDS OR INFORMATION
I authorize the release of any and all medical records, reports, imaging studies, labs, operative/path reports, visual data,
and any other requested information relating to my care at any facility including, but not limited to physicians, clinics,
hospitals, or other locations where I may have had tests/treatment. This material may be released to the Center for Weight
Loss Success, PC by FAX at (757) 873-1990 or other means, and I authorize the use of a copy of this form to be treated as
an original request in obtaining the material or data. Center for Weight Loss Success, PC staff has my full permission to
obtain this data on my behalf. I also authorize release of my medical records relating to my care and/or FMLA/Disability
FROM Center for Weight Loss Success, PC TO physicians/medical facilities/employer(s) and/or insurance company(s).
NOTICE OF DEEMED CONSENT TO HIV BLOOD TESTING
A law was enacted in Virginia in 1989 which authorizes health care providers to test their patients for HIV antibodies
when the health care provider is exposed to body fluids of a patient in a manner which may have transmitted human
immunodeficiency virus (HIV). Pursuant to this law, in the event of such exposure, you will be deemed to have consented
to such testing and to have consented to the release of the test results to the health care provider who may have been
exposed. However, you would be informed before any of your blood would be tested for HIV antibodies pursuant to this
provision, the testing would be explained to you and you would be given an opportunity to ask any questions you might
have.
My signature below is my consent that I understand and agree that the terms above apply to my current and future services
at Center for Weight Loss Success, PC.
Print Name:__________________________ Signature:____________________________
Date:_________________
New Patient Paperwork – 2019
WRITTEN ACKNOWLEDGEMENT FORM
NOTICE OF PRIVACY PRACTICES
Center for Weight Loss Success, PC
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Privacy Officer is Cat Williamson
Our Notice of Privacy Practice provides information about how we may use or disclose medical information about you. You may request a copy of our notice at any time. I,__________________________________(please print patient name) have been provided a copy of Center for Weight Loss Success, PC Notice of Privacy Practices. I have had an opportunity to read the Notice of Privacy Practice (Available at CFWLS) I understand that I may ask questions to Center for Weight Loss Success, PC, Privacy Officer if I do not understand any information contained in the Notice of Privacy Practice. ______________________________ Patient Signature ______________________________ Date ______________________________ Authorized Representative of Patient _____________________________ Relationship to Patient _____________________________ Date
New Patient Paperwork – 2019
Important information regarding the following consent: During your upcoming appointment with
Dr. Clark, he will refer to the information provided in his weight loss surgery webinar. Although it’s possible
that you have viewed or attended weight loss surgery classes in the past, it is required that you view Dr.
Clark’s webinar, as the information is specific to his weight loss surgery program. The webinar can be
located on our website at www.cfwls.com.
This statement is my acknowledgement that I have viewed Dr. Thomas W. Clark’s surgical webinar in full.
I agree that the surgical webinar provided thorough education on Banded Gastric Bypass, Laparoscopic
Adjustable Gastric Banding and Laparoscopic Sleeve Gastrectomy. Discussion for each procedure included but
was not limited to:
• short and long term risks
• weight loss results
• surgery and recovery times
• positives and negatives
• importance of incorporating nutritional education, exercise, and behavior modification for best chance
of long term success
Although Dr. Clark offers a live weight loss surgery seminar I have opted to view his webinar. I agree that I
understand the information discussed in the surgical webinar and will have the opportunity to ask questions
about my personal situation during my one on one consultation.
______________________________________________ ___________________
Patient Signature Date
New Patient Paperwork – 2019
ACKNOWLEDGEMENT OF INSURANCE VERIFICATION FOR WEIGHT LOSS SURGERY
(For Patients Who are Hoping to Use Insurance for Weight Loss Surgery)
Did You Know: If your insurance is administered through your employer, that it is the decision of your
employer (as to) whether or not the benefit (ryder) for weight loss surgery is available on your policy?
Prior to your appointment with Dr. Clark it is important that you have verified (that) this ryder which is specific
to weight loss surgery is in place. This can be done by calling the member/customer service number on your
insurance card; choose the option for eligibility and/or benefits; ask the question “Do I have the morbid obesity
ryder on my policy?” If the answer is yes, and you meet the national BMI requirements (listed below) for
weight loss surgery, then CFWLS has professional staff who will guide your through fulfilling your pre-
approval requirements. If the answer is no, then unfortunately this means that your insurance company is
contracted with your employer to “close the door” ie: deny the pre-approval request for weight loss surgery,
even starting with the one on one consultation.
If you find out that your insurance doesn’t cover weight loss surgery and you would like to explore Dr. Clark’s
self-pay Sleeve Gastrectomy program (lowest cost on the east coast with the most comprehensive program and
financing options available), give our office a call or visit our website at www.cfwls.com.
Patient’s with Medicare - Dr. Clark is not a provider of Medicare and/or Medicare products. If you have an
upcoming appointment with Dr. Clark and this has not been discussed, please call our office prior to your
appointment to assure that your questions concerning options have been answered.
Patient’s with United Healthcare – Although Dr. Clark is a provider of United Healthcare, the hospital where
surgery is performed (Sentara Careplex Hospital) is not on the UHC/Optum list of preferred facilities specific to
bariatric surgery
Insurance BMI (Body Mass Index) Requirements for Weight Loss Surgery – Insurance companies with the
weight loss surgery ryder in place typically recognize coverage (1) For patients who have a BMI of 40 or
greater OR (2) For patients who have a BMI as low as 35 if a clinical diagnosis of diabetes, high blood pressure
or sleep apnea are present. You can calculate your BMI by going to https://www.nhlbi.nih.gov/ and type
calculate your bmi in the search bar.
If you have questions concerning any of the information provided on this paper, please give our office a call.
Otherwise, your signature below is acknowledgement of your understanding.
_______________________________________________ ______________________________ Patient Signature Date
New Patient Paperwork – 2019
Please take a few minutes to answer the following questions and return this prior to
leaving the office today. This information will help our staff best serve your needs. This
information is also needed for the surgeon to complete a thorough review of your chart.
Today’s Date:_______________ Name:___________________________
Date of Birth:_______________ Zip: ________
I am interested in proceeding with surgery in:
0-3 months (make sure you schedule your computer test and psychologist appointment as soon as
possible)
3-6 months
Sometime within the next year
Unsure – I need additional information
How did you hear about our office? Drive By TV Radio Internet Ad
Internet Search: Sentara.com CFWLS.com Riverside.com Other
Your physician(s) (Please Specify) ___________________________________
Riverside Physician Sentara Physician Other ___________________________
Friend/Previous Patient (Please Specify so we can thank them) _____________________________
Interested in receiving our newsletter and other weight loss information from
Dr. Clark? YES NO
Please provide your E-mail address below We do not share your information with anyone else. You may stop receiving information at any time.
How may we BEST contact you?
Telephone: __________________________________
Email address: ________________________________
New Patient Paperwork – 2019
DIET HISTORY
Patient Name:_________________________Signature:_____________________
Date:__________________
PROGRAM MO./YR. START & END WT. LOSS WT. GAIN
WEIGHT WATCHERS __________________ ________ _______
WEIGHT LOSS FOREVER __________________ ________ ________
ATKINS __________________ ________ ________
NUTRA SYSTEM __________________ ________ ________
JENNY CRAIG __________________ ________ ________
PROTEIN SHAKES __________________ ________ ________
METABOLIFE __________________ ________ ________
LOW CALORIE __________________ ________ ________
HIGH PROTEIN __________________ ________ ________
KETO __________________ ________ ________
DIET PILLS __________________ ________ ________
NUTRITIONIST __________________ ________ ________
LOW FAT __________________ ________ ________
B12 SHOTS __________________ ________ ________
OTHER __________________ ________ ________
OTHER __________________ ________ ________
OTHER __________________ ________ ________
New Patient Paperwork – 2019
Patient Name:_______________________________
Date Completed:_____________________________
DO NOT LEAVE ANY LINE BLANK – MARK N/A IF IT DOES NOT APPLY
Date of Birth______________Age_______Marital Status M___S___D___W___Occupation____________
Height__________ Weight_________How long at this weight?_________________Goal weight________
Primary Care Physician_______________________How long has He/She been your PCP? _____________
PCP Address_______________________________ Phone Number_____________ Last Exam__________
Other physicians treating you?_____________________________________________________________
Health conditions currently being treated: ____________________________________________________
____________________________________________________________________________________________________________
________________________________________________________________
Have you ever been under the care of a psychiatrist or psychologist? □ No □ Yes
If yes, with whom and when? ______________________________________________________________
Treatment plan: □Counseling □ Hospitalization □ Medications: __________________________________
Still under treatment? □ Yes □ No
DO YOU HAVE OR HAVE
YOU HAD
YES NO DON’T KNOW
Diabetes
High Blood Pressure
High Cholesterol
High Triglycerides
Angina/Coronary
Artery Disease
Heart Attack
Heart Arrhythmia
Sleep Apnea
LIST OF CURRENT MEDICATIONS: (Include OTC & Vitamins)
Medication Allergies: □ No □Yes If yes, please list:
____________________________________________________________________________________________________________
______________________________________________________________________________________________
CENTER FOR WEIGHT LOSS SUCCESS, PC
HEALTH /LIFESTYLE EVALUATION
NAME OF MEDICATION STRENGTH HOW OFTEN REASON FOR MED
New Patient Paperwork – 2019
LIST ANY MAJOR ILLNESSES:
Illness Date Treatment Outcome
LIST ANY SURGERIES:
Surgery Date Reason
FAMILY HISTORY
YES NO MOTHER FATHER SIBLING CHILD
Being Overweight
Diabetes
High Blood
Pressure
Heart Disease
Stroke
Arthritis
Cancer
Thyroid Disorder
GYN HISTORY (If Applicable)
Yes No Have you been treated for infertility?
Yes No History of PCOS
Yes No Regular Menstrual Periods
Yes No Menopausal
If yes, year of onset______
Yes No Pregnancies
If yes, number of deliveries_____
Other: ____________________________________
Who is your Ob/Gyn physician? _________________________________
URINARY PROBLEMS
Do you ever involuntarily lose your urine? Yes______ No______
HEARTBURN AND/OR INDIGESTION
Do you have indigestion or heartburn? Yes_____ No_____ If yes, for how long______________
Have you ever had an endoscopy? Yes_____ No_____ If yes, date of procedure______________
Have you ever had a colonoscopy? Yes_____ No_____If yes, date of procedure______________
New Patient Paperwork – 2019
BREATHING PROBLEMS
Have you been evaluated by a pulmonologist? Yes_____ No_____ If yes, complete the following:
Name of physician___________________________ Phone number________________________
Do you experience shortness of breath with physical activity? Yes_____ No_____
Do you snore? Yes_____ No_____
Have you been diagnosed with sleep apnea? Yes_____ No_____
Do you use a C-Pap or BI-Pap machine? Yes_____ No _____
Do you ever stop breathing while asleep? Yes_____ No_____
Do you have or have you had asthma? Yes_____ No_____
Do you suffer with chronic bronchitis? Yes_____ No_____
BONE OR JOINT PROBLEMS
Do you have any of the following: Please Indicate
LOCATION SWELLING PAIN STIFFNESS POPPING/CRACKLING
Ankle
Knees
Hips
Back
Other
Have you ever been told you have degenerative change or early arthritic changes in your joints? Yes_____ No_____ If yes, please
explain:______________________________________________
Have you ever been treated for bone or joint problems? Yes_____ No_____ If yes, Please indicate (including physical therapy and
chiropractic)__________________________________________________
Yes No Have you ever smoked cigarettes?
If yes, what was the most you ever smoked? _____________________
How much do you smoke now? ____________________________
Yes No Do you drink coffee or tea?
If yes, how many caffeinated cups do you drink per day? _________
How many decaffeinated cups do you drink per day? ______________
Yes No Do you drink cola or soft drinks?
If yes, how many caffeinated drinks per day? __________________
How many decaffeinated drinks per day? _____________________
Please specify: ________regular soda___________ diet soda
Yes No Do you drink alcohol?
If yes, how many servings do you drink per day? ______________
Please specify: ____beer ____wine ____liquor _____other
Yes No Do you ever feel out of control with your eating?
If yes, please describe how this feels and how often this occurs
__________________________________________________
New Patient Paperwork – 2019
Do you have or have you ever had any of the following symptoms/problems/concerns?
YES NO SYMPTOM/PROBLEM/CONCERN DETAIL/COMMENTS
High Blood Pressure Readings
Elevated Blood Sugar Readings
Frequent or Severe Fatigue/Weakness
Polycystic Ovarian Disease
Frequent or Severe Headaches
Nasal Congestion
Chronic Sinus Congestion
Dental Problems
Dentures
Heart Murmur
Chest Pain with Activity or Exercise
Heartburn
Pain or Discomfort after Eating
Bloating
History of Kidney Problems
History of Liver Problems
History of Hepatitis Type:
History of HIV Infection
Anemia
Constipation
Bleeding Tendency
Convulsion or Seizures
Paralysis, Numbness or Tingling
Slow Metabolism
Depression
Anxiety
Sleep Problems
Drug or Alcohol Abuse
Chronic Skin Rash or Hives
Chronic Skin Infections of Lower Legs
Chronic Skin Infections Under Breasts
Varicose Veins of Legs
Gout
Fibromyalgia
Shortness of Breath when Walking
Chronic Pain
Anorexia
Bulimia
Suicidal Thoughts/Attempts
Being Overweight has affected:
❑ Family Life
❑ Social Life
❑ Emotionally
❑ Unable to find a job
❑ Exercise or Sports
Reviewed by:___________________________________________________ Date:_________________________
New Patient Paperwork – 2019
Phone (757) 873-1880
Fax (757) 873-1990
Sleep Apnea Risk Assessment Form – Fax 757-827-2199
PLEASE CALL PATIENT BELOW TO MAKE AN APPOINTMENT
The problem of sleep apnea is very common among our patient population. Sleep apnea can affect your overall health and is
important to diagnose and treat. We also find that the diagnosis of sleep apnea can expedite your insurance approval process for
weight loss surgery. Please take a minute to fill out this screening questionnaire.
Have you been diagnosed with sleep apnea? □ Yes □ No □ I don’t know
Parameter Question Score
Snoring Do you snore loudly (louder than talking or
loud enough to be heard through closed
doors?
□ No= 0
□ Yes = 1
Tired Do you often feel tired, fatigued, or sleepy
during daytime?
□ No= 0
□ Yes = 1
Observed Has anyone observed you stop breathing
during your sleep?
□ No= 0
□ Yes = 1
Blood
Pressure
Do you or are you being treated for high
blood pressure?
□ No= 0
□ Yes = 1
BMI BMI ________kg/m2 . Is the BMI more than
35 kg/m2?
□ No= 0
□ Yes = 1
Age Age over 50 years old? □ No= 0
□ Yes = 1
Neck
Circumference
Neck circumference measured ____(inches or cm)
or indicate collar size of shirt, i.e., S, M, L, XL, or
____. Neck circumference greater than 16 inches
(40cm)
□ No= 0
□ Yes = 1
Gender Gender male? □ No= 0
□ Yes = 1
Total
Score
If your score is 3 or more, there is a significant chance that you have sleep apnea.
We would be happy to refer you to one of the Sentara Sleep Centers for evaluation (Hampton or Williamsburg)
□ I would like to be evaluated further and consent to referral □ Not at this time
I would prefer: □ Hampton □ Williamsburg
Name (print)___________________________ Phone___________________ □Cell □ Home
Signature________________________________ Email__________________________